Group Rate - Women's Self-Defense

Step 1 - Select date and quantity below, hit submit and fill out pop-up form to add to cart

Step 2 - Fill out waiver

Main Contact Name *

Main Contact Name

First Name

Last Name

Email Address *

PHYSICAL HISTORY

BEFORE YOU TAKE THIS CLASS, WE ASK THAT YOU COMPLETE SOME BRIEF HEALTH INFORMATION, SO THAT WE CAN KNOW IF ANYONE HAS ANY SPECIAL NEEDS. IF ANYONE IS OVER 69 YEARS OF AGE AND/OR YOU ARE NOT USED TO BEING ACTIVE, CHECK WITH YOUR DOCTOR.

Does anyone have any physical or mental disabilities or challenges that might affect your exercising? *

If you chose yes above, please explain with person(s) name and reason:

Through any of your own experiences or a doctor's advice, is there any reason anyone shouldn't exercise? *

If you chose yes above, please explain with person(s) name and reason:

IF YOU ANSWERED YES TO ONE OR MORE QUESTIONS, YOU SHOULD CONSULT YOUR DOCTOR BEFORE BECOMING MORE PHYSICALLY ACTIVE.

Do you or the other attendees have any injuries that you would like to disclose? *

If you chose yes above, please explain with person(s) name and reason:

WAIVER/RELEASE OF LIABILITY

IN CONSIDERATION OF YOUR ACCEPTANCE OF THIS FORM, I FOR MYSELF, MY HEIRS, EXECUTORS, OTHER PEOPLE ON THIS FORM, ADMINISTRATORS AND ASSIGNS, FOREVER WAIVE, RELEASE AND DISCHARGE ANY AND ALL RIGHTS, CLAIMS FOR DAMAGES, UNKNOWN, THAT I MAY HAVE AGAINST ONE WITH HEART, THEIR EMPLOYEES, MEMBERS, OR INSTRUCTORS, FOR ANY AND ALL INJURIES IN ANY MANNER ARISING OR RESULTING FROM MY PARTICIPATION IN CLASSES. I ATTEST AND VERIFY THAT I HAVE FULL KNOWLEDGE OF THE RISKS INVOLVED IN ANY MARTIAL ARTS, WEIGHTS, EXERCISE, AND FITNESS PROGRAMS AND THAT I FREELY AND VOLUNTARILY ASSUME THOSE RISKS AS INCIDENT TO PARTICIPATION, AND THAT I WILL ASSUME AND PAY MY OWN MEDICAL AND EMERGENCY EXPENSES IN THE EVENT OF ACCIDENT, ILLNESS, OR OTHER INCAPACITY, REGARDLESS OF WHETHER I HAVE AUTHORIZED SUCH EXPENSES, AND THAT I AM MEDICALLY AND PHYSICALLY FIT AND ABLE TO PARTICIPATE IN CLASSES. I ALSO GIVE CONSENT TO ONE WITH HEART, ITS OWNER, TEACHERS, EMPLOYEES, AND OTHER STUDENTS TO GIVE MINOR EMERGENCY FIRST AID AND/OR ADVICE TO ME. I HEREBY RELEASE CLAIMS I HAVE TOWARDS THEM FOR GIVING ME SUCH TREATMENT. ALL DUES AND PAYMENTS FOR CLASSES ARE NONREFUNDABLE AND NON-TRANSFERABLE. ONE WITH HEART HAS THE RIGHT TO CANCEL CLASSES AND WORKSHOPS DUE TO INCLEMENT WEATHER FOR THE SAFETY OF ONE WITH HEARTS MEMBERS. REFUNDS WILL BE GIVEN FOR WORKSHOPS BUT NO PRORATES FOR ON-GOING CLASSES. I GIVE ONE WITH HEART PERMISSION TO USE ANY PHOTOS/VIDEOS TAKEN OF ME FOR PUBLICITY.

Participants Signature *

Parent or Legal Guardian Signature (If under 18 years old)

How did you hear about us? (Facebook, Google Search, Yelp, Friend, Etc) *

If you were referred, who can we thank?

GET UPDATES AND INFORMATION ABOUT ONE WITH HEART BY SIGNING UP FOR THE E-NEWSLETTER